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Chronic Sinusitis and Pott’s Puffy tumor
Line-Nitu, E, D.O., Andreozzi, M,D.O.
Kent Hospital, Warwick, RI
Introduction: Pott’s Puffy Tumor was first identified in 1760. It is an unusual
complication of acute or chronic bacterial sinusitis, leading to osteomyelitis of the frontal
bone, with associated subperiosteal abscess. Since 1990, literature reports only 32
cases of adult Pott’s Puffy Tumor; male gender predominates. Common causes are
head trauma, acute/chronic bacterial sinusitis, intranasal cocaine use. It is noticed
predominantly in the adolescent age group, 15-17 year olds, and not in adults. MRI is
the gold standard imaging. The following is the unique case of an older female patient,
initially exhibiting signs of simple chronic sinusitis and headache. A series of imaging
studies demonstrated infection of the skin and frontal subcutaneous tissue involving the
bone, extending to the dura, with the final diagnosis of follicular B cell lymphoma.
Case: This is a 63 year old female presented to the ear nose throat (ENT) specialist in
May 2012. She complained of frontal headaches, and an episode of right-side forehead
swelling, with radiation of pain to the top of the head and eye region. She denied any
periorbital swelling; and the headache was somewhat controlled. During this time, the
forehead swelling subsided without antibiotic treatment. PMHx is positive for chronic
sinusitis characterized by chronic nasal congestion, rhinorrhea, hypothyroidism, asthma,
GERD, sinus surgery, C-section, cholecystectomy. Denied any alcohol, smoking, drugs
and any trauma or history of coronary artery disease, hypertension, bleeding disorder,
diabetes, seizures, weight loss, night sweats, fever, chills, travel. Within a couple of
weeks in June, swelling in the same area returned with an intensity of pain 10/10 that
was not controlled with narcotics. The subsequent 8 weeks the patient was treated with
multiple courses of antibiotics, including amoxicillin/clavulonic acid and levofloxacin. CT
of sinuses in July showed some frontal and maxillary sinus disease without infectious
symptoms. Patient was afebrile, vital stable, CBC, BMP normal. On physical exam, a
right forehead tender lump noted. In 09/2012 CT and MRI of sinuses was again
recommended. due to minimal improvement. Imaging still showed mucosal thickening
and the left frontal sinus completely blocked, with no intracranial fluid. MRI revealed
infection over the frontal bone with thickening of the subcutaneous tissue and
inflammation extending to the dura. This was identified as Pott’s puffy tumor. Surgical
intervention was necessary in 10/2012 to drain the affected sinus and excise the infected
bone. Bicoronal craniotomy was performed, purulent material removed from the frontal
sinus, an epidural abscess drained and biopsy and cultures were obtained and sent to
pathology. Cultures were negative and Gram stain showed no organisms, 2+ WBC.
Pathology results with immunohistochemical stains showed low grade follicular B cell
lymphoma. Because of the epidural abscess and cancer diagnosis, the patient is closely
followed by infectious disease and hematology/oncology
Discussion: This unique case of Pott’s Puffy Tumor helps illustrate the importance of
the clinician’s understanding of the pathophysiology of this rare condition. Timely
referral, high index of suspicion, and close observation are crucial for a good clinical
outcome. The lymphoma led to the obstruction of ventilation of the sinus cavity which led
to the sinusitis extension into osteomylitis hence the finding of Pott’s puffy tumor.